One health issue which is poorly understood and even less talked about in India is menstrual health and hygiene. Lack of access to toilets, sanitary napkins and even awareness regarding the issue can pose a major health and safety risk for girls across the country. This is compounded by poverty and the inability to access menstrual hygiene products even when there is awareness about its usage. In 2010, Water Aid India reported that only 7% of the women surveyed used sanitary napkins and only 50% of women were aware of their usage.
This problem is augmented by the fact that open discussions about menstruation still remain taboo, especially in rural areas. A variety of restrictions are placed on women when they are on their periods in terms of access and mobility. Lack of access to proper sanitary products leads to a situation wherein women and young girls are forced to use old pieces of cloth or rags that are unsanitary and can lead to infection. The absence of products coupled with inadequate access to toilets in schools leads to a high rate of school dropouts and absences among young girls when they start their period. The issue affects both the health and education of girls.
A persistent issue
Despite the fact that the Ministry of Drinking Water and Sanitation has given comprehensive national guidelines on Menstrual Hygiene and Management (MHM), the issue persists. The framework encompasses access (in terms of knowledge of absorbents and their disposal), infrastructure (water, sanitation and hygiene), awareness (societal, familial and individual levels) and support. The guidelines aim to secure dignity and allow girls and women to stay in schools.
The Ministry of Women and Child Development also addresses the issue of menstrual health by training anganwadis, generating demand and production of sanitary napkins, reaching out to schools and providing MHM facilities in shelter homes. The Ministry of Human Resource Development reaches out through schools aiming at gender sensitisation and peer support to promote MHM.
However, the numbers are dismal. The national guidelines note the severity of the situation from a 2012 UNICEF report: there is almost no discussion around menstruation. Around 90% of women are unaware of the importance of using sanitary napkins. 87% continue to use old pieces of cloth as absorbents, with the result being that 79% suffer from low confidence, 60% miss school and 44% feel humiliated. The guidelines recognise MHM as a “social issue” necessitating changes in family and community norms. To break stigmas around this issue, great importance is placed on “breaking the silence”. There is a need for government officials and teachers “to find appropriate ways to talk about the issue and take necessary actions”.
Yet, this idea remains elusive on the ground. Poor engagement stems from little or no community involvement. Young girls and women struggle to articulate their needs in order to generate demand at the village level. There is often no safe space or platform where a dialogue regarding this issue can be facilitated and knowledge disseminated. One community health trainer noted that notions of impurity during menstruation were so deeply embedded in the psyche of women that not only would they avoid bathing, worship and cooking during their periods, but they also steered away from places of worship and the kitchen.
The Rajiv Gandhi Mahila Vikas Pariyojana (RGMVP), a non-profit working to alleviate poverty and build social capital in Uttar Pradesh, places importance on facilitating community dialogues through women’s self-help groups (SHGs). With the Bill & Melinda Gates Foundation, International Centre for Research on Women and Shramik Bharti, they decided to test if women’s collectives and community development programmes improved sanitation and hygiene behaviours and increased knowledge and practice of menstrual hygiene. The assumption being that firstly, collectives serve as women-only safe spaces where discussions on women’s health and hygiene can be openly facilitated. Secondly, collectives build women’s agency and lead to demands for safe menstrual products from the health centres and community health workers.
The first step was capacity-building and training activities in Water, Sanitation and Hygiene (WASH). This was executed through social mapping and sensitising key functionaries of the village. These included influencers like the village pradhan, key government health functionaries – the Accredited Social Health Activist (ASHAs), Anganwadis (AWW, ICDS staff), the Auxiliary Nurse Midwives (ANMs) as well as the officials from the village health and sanitation committees. It also included RGMVP’s key social capital in the form of SHG members, the swasthya sakhis (village health workers) and community health trainers.
The second step was to organise a number of awareness events in selected villages. All the events were based on the principle of community involvement with special efforts to include men, women and adolescents. The facilitators and the trainers were largely drawn from the community. The trainings included interactive puppet shows, school meetings and movie screenings, night meetings, safai abhiyan rallies (cleanliness rallies) and aam sabha (general body) meetings. Special menstrual hygiene management (MHM) trainings were organised by the community health trainers to promote the proper use and disposal of sanitary pads in the village. Particular attention was given to educating the young girls on the importance of ASHAs and their role in facilitating the distribution of low cost sanitary napkins in the village, in order to generate demand-driven results.
All these trainings were accompanied by strengthening the capacity of existing SHGs and the formation of new SHGs to use them as social platforms for disseminating messages. The SHGs were understood to be safe and women-friendly spaces where menstrual issues and women’s health and hygiene could be openly discussed and relevant information disseminated. Special focus was placed on building new Young Women SHGs (YWSHGs) and strengthening the capacities of existing ones. These catered to young unmarried girls aged 13-21 with adolescent sexual and reproductive health being one of the main agendas.
The results of such intensive intervention modelled on the principle of community involvement were successful and offered new insights. Increase in knowledge and awareness led to a visibly significant increase in the usage of sanitary napkins. ASHA’s contribution increased the supply of menstrual hygiene products; women and girls made the ASHAs accountable for the supply.
Attitudes towards menstruation reflected a mixed trend. More than three-fourths of the women in the community across all villages had experienced some form of restriction (social as well as physical) around menstruation. However, the outcomes revealed that women and girls exposed to such trainings displayed lower stigma and embarrassment and no longer missed schools. The used pads were either buried or burnt for safe disposal.
Thus, adopting safe MHM practices ultimately needs to be a demand-driven process with the expectation of information, education and communication activities leading to behavioural changes. In this respect, there is great scope to explore RGMVP’s model of SHGs. They may be regarded as social platforms to examine the influence of MHM trainings on the individual, family and community levels, contributing to systems of information management for initiating dialogue around sensitive issues at large.
Swati Saxena is a researcher at a non-profit organisation. She has a Ph.D in public health and policy from the London School and Hygiene and Tropical Medicine and an M.Phil in Development Studies from the University of Oxford.